Correction of Crossover Toe Deformity by Arthroscopically Assisted Plantar Plate Tenodesis

Abstract

Plantar plate deficiency is the major pathology causing metatarsophalangeal joint instability. As the joint subluxates dorsally, the lumbrical is tethered at the medial side of the joint by the deep metatarsal ligament and becomes a deforming force for the development of crossover toe deformity. Plantar plate repair or reconstruction is a logical surgical treatment option. This can be performed through a dorsal or plantar approach. The purpose of this technical note is to report a minimally invasive technique of crossover toe deformity correction by suturing the plantar plate to the extensor tendon. It is indicated for symptomatic crossover toe deformity that is not responsive to nonsurgical treatment. It is contraindicated if the metatarsophalangeal joint is degenerated, destructed, or dislocated, or there is interdigital neuroma at the sides of the deformed toe, or the deformity is caused by bony deformities of the metatarsal head or the proximal phalanx.C rossover second toe is one of the common forefoot deformities. Plantar plate insufficiency is the most common cause. It may progress with time to toe coronal and sagittal plane malalignment and even frank metatarsophalangeal (MTP) joint dislocation. 1,2 Conservative treatment including the toe splint can rarely delay the progression. Surgical treatments of this deformity include soft tissue balancing procedures to stabilize the MTP joint (plantar plate repair, tendon release or transfer, and periarticular soft-tissue release) and/or bony procedures (metatarsal/phalangeal osteotomy, arthrodesis, and excisional arthroplasty), and even toe amputation. 3 The Girdlestone-Taylor flexor-to-extensor tendon transfer is an effective method to stabilize the sagittal alignment of the MTP joint, but it may not be able to restore a normal coronal alignment of the MTP joint in crossover toe deformity. [4][5][6] Postoperative toe stiffness is also common after the transfer. 2,5,7 Plantar plate repair has the advantage of addressing the plantar plate insufficiency that is the primary pathology of instability of the MTP joint. It has been shown that plantar plate repair is as effective as tendon transfer in stabilization of the MTP joint with less postoperative stiffness and discomfort. 5 Tears of the plantar plate can be treated by primary repair with or without the use of suture anchor or distal advancement of the plate to the base of the proximal phalanx through bone tunnels. 8 It can be performed through the plantar 2,7 or dorsal 3,8-17 approaches. The plantar approach can reach the plantar plate directly. However, blunt dissection at the plantar wound may disrupt the organized fat septae resulting in extensive plantar scarring. 7 The dorsal approach has the advantage of avoidance of plantar dissection and scar formation. Concomitant procedures, for example, periarticular soft tissue release, extensor tendon lengthening, and Weil metatarsal osteotomy, can be performed together with repair of the plantar plate through the same dorsal incision. 3,[8][9][10][11][12...

Extraction of the Proximal Phalanx: A New Option in Surgical Treatment of the Crossover Second Toe

“…As we mentioned before, very often associated with the crossover toe deformity, it is possible to find a rupture of the plantar plate [6]. The plantar plate has an important role in metatarsophalangeal stability, and many authors described their techniques for reconstruction of the plantar plate [13][14][15]. Reconstruction of the plantar plate is a very helpful and successful procedure in mild-to-moderate stages of deformity, where we have instability of the MTP joint.…”

Correction of Crossover Toe Deformity by Plantar Plate Tenodesis and Arthroscopic Release of Lumbrical

“…massive or complicated tear or if the quality of the tissue is poor because the fibrous tendon sheath is incorporated into the construct. 5,23 The advantages of this technique include complete medial soft-tissue release, precise placement of the suture to the plantar plate under arthroscopic guidance, minimal soft-tissue dissection, and avoidance of plantar wounds; in addition, the tendons of the toes can be preserved, and sophisticated instruments are not needed. The potential risks of this technique include injury to the articular cartilage, injury to the interdigital nerve, recurrent or residual deformity, and reduced active toe motion (Table 3).…”

“…The patient is advised to follow a non–weight-bearing protocol for 2 weeks and then allowed weight-bearing walking as tolerated with a wooden-based sandal for another 4 weeks before resuming normal shoe wear. 5

Fig 5 Correction of crossover toe deformity of left second toe by plantar plate tenodesis and arthroscopic release of lumbrical. The patient is in the supine position.

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“…3,4 Conservative treatment including toe splints can rarely delay the progression, and surgical treatment is needed in symptomatic cases. 5 Surgical treatment of this deformity includes soft-tissue balancing procedures to stabilize the MTP joint (plantar plate repair, tendon release or transfer, and periarticular soft-tissue release) and/or bony procedures (metatarsal and/or phalangeal osteotomy, arthrodesis, and excisional arthroplasty) and even toe amputation. 6 The Girdlestone-Taylor flexor-to-extensor tendon transfer is an effective method to stabilize the sagittal alignment of the MTP joint, but it may not be able to restore the normal coronal alignment of the MTP joint in crossover toe deformity.…”

“…Plantar plate tenodesis, an arthroscopically assisted dynamic repair of the plantar plate, has been described to correct the claw toe deformity by stabilizing the attenuated plantar plate through suturing of the plantar plate with the extensor tendon. 4 , 5 , 16 , 17 , 18 This arthroscopically assisted procedure allows adequate visualization of the operative field without the need for extensive soft-tissue dissection. Because tethering of the lumbrical contributes to development of crossover toe deformity, in this Technical Note, we report a modification of the plantar plate tenodesis and incorporate endoscopic lumbrical release into the technique.…”